Laparoscopic Radical Cystectomy with Ileal Conduit Diversion The

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					Case Report

    Laparoscopic Radical Cystectomy with Ileal Conduit
       Diversion: The First Case Report in Thailand
                              Kittinut Kijvikai MD*, Suthep Patcharatrakul MD**,
                       Wisoot Kongchareonsombat MD***, Charuspong Dissaranan MD*

* Division of Urology, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University
                  ** Division of Urology, Department of Surgery, Police General Hospital
 *** Division of Urology, Department of Surgery, Bangkok Metropolitan Administration Medical College
                                            and Vajira Hospital


Objective: To report the authors’ first experience on a surgical technique for laparoscopic radical cystectomy
with ileal conduit diversion.
Material and Method: A 55 year-old man, weighing 65 Kg with histology proven T 2 transitional cell
carcinoma of the urinary bladder underwent laparoscopic radical cystectomy with ileal conduit diversion.
The cystoprostatectomy was performed by laparoscopic technique, whereas ileal conduit and stroma were
performed through a mini-laparotomy.
Results: The procedure was performed successfully without open conversion. The operation time was 350 min.
Estimated blood loss was 1,100 ml. Only 6 mg morphine was needed for postoperative pain relief. The surgical
margins were free from tumor. The hospital stay was 8 days. The patient returned to his normal activities 3
weeks after surgery.
Conclusion: Laparoscopic radical cystectomy with ileal conduit diversion was a feasible and safe operation
for muscle invasive carcinoma of the urinary bladder. However, the procedure needed a steep learning curve
and should be performed in centers having experience in laparoscopic surgery.

Keywords: Radical cystectomy, Ileal conduit diversion, Laparoscopy

J Med Assoc Thai 2005; 88 (12): 1947-51
Full text. e-Journal: http://www.medassocthai.org/journal



         Radical cystectomy is the gold standard treat-           radical cystectomy and ileal conduit urinary diversion
ment for invasive bladder cancer(1). However, it is a             in a male patient.
major surgical procedure and may incur significant
operative blood loss. Laparoscopic cystectomy has                 Case Report
been described and it has been proven to be feasible(2,3).        Case history
Nevertheless, its role, advantages and potential com-                       A 55-year-old man with no underlying disease
plications should be defined. The technical aspects of            presented with 4 months’ history of painless gross
laparoscopic cystectomy are not well standardized                 hematuria. A cystoscopy revealed a multiple sessile
and most operations are performed in well equipped                bladder tumor, 2-3 cm in diameter, involving the ante-
centers for laparoscopic surgery.                                 rior, posterior, left and right lateral bladder wall. A com-
         In the present report, the authors describe              puted tomography (CT) scan of the abdomen and
the technique for the first successful laparoscopic               pelvis confirmed the presence of the lesion without
                                                                  any evidence of metastatic disease. A transurethral
Correspondence to : Kijvikai K, Division of Urology, Department   resection of the bladder tumor (TUR-BT) was performed
of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, 270 Rama 6 Rd, Tungphyatai, Rajathevee, Bangkok
                                                                  and the pathology report was consistent with a G 2 T 2
10400, Thailand. Phonn: 0-2201-1315, Fax: 0-22011316,             transitional cell carcinoma of the bladder. After having
E-mail: kittinutk@hotmail.com                                     been explained about the risk, benefits, and possible


J Med Assoc Thai Vol. 88 No. 12 2005                                                                                    1947
complications of different therapeutic options, the            establishment of the pneumoperitoneum. The abdo-
patient signed consent to undergo a laparoscopic               men and pelvis were then carefully inspected.
radical cystectomy with ileal conduit urinary diversion.
                                                               2. Denonvilliers’ fascia incision
Technique                                                                The peritoneum was incised at the level of
Patient’s preparation                                          the rectovesical cul-de-sac and the vas deferens were
          The patient received a standard bowel prepa-         identified and divided bilaterally. Dissection was per-
ration with electrolytes on the day before the surgical        formed toward Denonvilliers’ fascia and the tips of the
procedure. He was given an antibiotic for prophylaxis          seminal vesicles. After identification of Denonvilliers’
with a second generation cephalosporin (cefoxitin 1 g x        fascia, the fascia was incised in the midline to expose
2) at the induction of anesthesia which was continued          the perirectal fat. The fibers of the rectum were bluntly
for 24 postoperative hours. Lower extremities compres-         pushed away posteriorly from the prostate by laparo-
sive devices were applied before starting the proce-           scopic fan retractor. This dissection was carried down
dure. The patient was placed in the modified lithotomy         as far as possible to the apex of the prostate. The semi-
abducted-thighs and Trendelenburg position, while              nal vesicles and vas deferens were then mobilized en
a nasogastric tube was inserted and a 18 Fr. Foley             bloc with bladder specimen. Complete mobilization of
catheter was placed for drainage of the urine.                 the rectum was crucial in order to better define the
                                                               prostatic and vesical pedicles and to prevent rectal
Surgical technique                                             injuries.
1. Laparoscopic access                                                   The ureters were dissected down to the blad-
          A 5-port transperitoneal approach was used           der wall with care to keep their vascular supply intact
(Fig. 1). The first 12-mm trocar was placed with open          and the distal ureteral margins were sent for pathologic
technique through a mini-laparotomy just below the             frozen section examination.
umbilicus. This trocar was reserved for the laparoscope.
The remaining 4 (12-mm x 3, 5-mm x 1) ports were placed        3. Exposure of endopelvic fascia and dorsal venous
in a fan-shape fashion under endoscopic control after          complex control
                                                                         Incision of the peritoneum was carried out
                                                               along the external iliac artery and extended distally to
                                                               the abdominal wall lateral to the umbilical ligaments,
                                                               and proximally to the common iliac artery. At the level
                                                               of the pubic bone, the bladder and perivesical fat were
                                                               dissected freely from the pelvic wall with exposure of
                                                               the endopelvic fascia. The fascia was incised closely
                                                               to the prostate bilaterally and the fibers of the levator
                                                               muscle was carefully dissected. The dorsal vein com-
                                                               plex and the prostatic apex were then carefully iso-
                                                               lated.
                                                                         A 1-0 Monocryl absorbable suture was
                                                               passed and encircled two rounds over the dorsal vein
                                                               complex and the dorsal vein complex was then ligated.

                                                               4. Vesical and prostatic pedicles incision
                                                                         At this time the assistant surgeon pulled the
                                                               bladder upward and toward the right side of the pelvis
                                                               by using a grasper with the left hand, while in the
Fig. 1 A picture showing 5 ports placement in a fan-shaped
                                                               meantime with the right hand he pushed with the fan
       fashion for cystoprostatectomy and a laparotomy
                                                               retractor downward the rectum in order to expose the
       incision for both specimen extraction and extracor-
       poreal ileal conduit reconstruction. The 0 and 30       left vesicoprostatic pedicle. With the use of LigaSure
       degree laparoscope was inserted through the umbili-     device and bipolar forceps the vesical and prostatic
       cal port. The right pararectus muscle port was chosen   pedicles were progressively divided. Then, the blad-
       to be the stromal site of the conduit                   der was pulled by the surgeon on the left side while the


1948                                                                             J Med Assoc Thai Vol. 88 No. 12 2005
fan retractor continued to push the rectum downward          duit diversion and bilateral Bricker ureteroileal anas-
in order to divide the right vascular pedicle in the same    tomosis. The estimated blood loss was 1,100 ml, and 4
manner as the left side.                                     units of blood transfusion were replaced.
                                                                       The patient resumed oral intake on the third
5. Apex incision                                             postoperative day. A total of 6 mg of morphine was
           After ligation, the dorsal vein complex was       used for pain relief. The drain was removed on day-5.
then divided and the anterior urethral wall was incised.     The ureteral stents were removed on postoperative
The distal end of the catheter was ligated, transected       day-7. He was discharged from the hospital on post-
and pulled into the abdominal cavity, maintaining the        operative day-8.
balloon inflated in the bladder to avoid intraabdominal                Histopathology showed muscle invasive TCC
urine contamination. The posterior wall of the urethra       of the bladder without lymph node metastasis. The
was divided. The rectourethralis muscle and the distal       surgical margins were free. The total number of pelvic
insertions of Denonvilliers’ fascia were incised in order    lymph nodes dissection was 7 on the left side and 10
to totally release a specimen which was then entrapped       on the right side, respectively. A follow-up serum creati-
in an endosac bag.                                           nine and electrolytes were within normal limits. After 3
                                                             weeks, the patient could return to his normal activities.
6. Bilateral pelvic lymph node dissection
         A bilateral pelvic lymph node dissection was        Discussion
performed with the same boundaries as in an open                        Open radical cystectomy is the gold standard
surgery.                                                     of treatment for muscle invasive bladder cancer(1). This
                                                             operation requires a long abdominal incision with pro-
7. Specimen retrieval and creation of the ileal conduit      longed retraction of the abdominal wall. This maneu-
           A 7-cm incision was then performed at the         ver leads to a high level of postoperative pain, often re-
lower midline, starting from the umbilicus (Fig. 1). The     quiring a large amount of opioid medication for several
specimen was retrieved and the suspended sutures of          days. Consequently, the patients remain hospitalized
the ureters were exteriorized. The distal ileum was iden-    with continuing care for a long time and need a long
tified and brought in front of the abdominal wall. A         period of rest before returning to the normal activities.
segment of 15-cm ileum proximal to ileocecal valve was       All of these may cause fear among patients and sur-
isolated with GIA stapler. The continuity of the bowel       geons, and these can also make the patients postpone
was re-established performing a functional double layer      the operation, which may result in a worsening prog-
end-to-end anastomosis using 3-0 Monocryl absorb-            nosis.
able suture. The mesentery was reapproximated using                     Several authors(4-8) have demonstrated that
absorbable sutures and the distal ileum relocated in         laparoscopic cystectomy is feasible with lower mor-
the abdomen. The distal ureters were brought in the          bidity and shorter hospital stay than the open proce-
operative field. The spatulated ureters were stented         dure. Some authors have reported a lower incidence of
and anastomosed in a Bricker fashion to the ileal con-       postoperative ileus after the laparoscopic approach
duit utilizing 4-0 Monocryl sutures. The proximal end        when compared with the open surgery approach,
of the conduit was replaced in the abdomen. The right        principally due to less manipulation of the bowel and
pararectus muscle port was chosen to be the stomal site.     fewer opioids are necessary to control pain postopera-
           Pneumoperitoneum was reestablished and            tively(9,10). Moreover, magnification of the optical in-
the proper placement of the ileal conduit was confirmed.     strumentation can enable more precise dissection with
A small drain was left in the pelvis. The fascia of the 10   less blood loss and better preservation of anatomical
mm port site was closed under direct vision with 1-0         structures(11). Laparoscopic cystectomy with different
Vicryl absorbable suture. The pneumoperitoneum was           types of urinary diversions has been reported by
released and the procedure was completely finished.          numerous authors(4-9,11-15).
                                                                        In the present report, the authors have
Results                                                      shown their first experience in the cystectomy step. All
         The laparoscopic procedure was completed            authors utilized a transperitoneal approach with 4
without intraoperative complications or need for open        ports(5,6) ports(7,9,12-15) or 6 ports(8). The authors have
conversion. The total operative time was 350 min; 230        been using 5 ports in a fan-shape fashion. Lympha-
minutes for cystectomy and 120 minutes for ileal con-        denectomy was performed after cystectomy which was


J Med Assoc Thai Vol. 88 No. 12 2005                                                                              1949
the same as that of some authors(6,8) However, the            better preservation of anatomical structures. Laparo-
others have performed before(7,9,12,14,15) or in the middle   scopic radical cystectomy should therefore be the
of the procedure(13). The authors dissected the posterior     operation for experienced laparoscopic surgeons. But
part of the bladder first by following the vas deferens       in the authors’ opinion, this procedure may be prac-
and seminal vesicle. The lateral and posterior vascular       ticed in every academic center. The results from the
pedicles of the bladder and prostate are controlled with      presented technique described in this report are en-
sequential firings of the Endo-GIA stapler by many            couraging and it is believed that a better outcome can
authors(6-10,13-15), but in the authors’ opinion multiple     be obtained if more experience is gained.
firings of the Endo-GIA stapler may result in increasing
the costs of the operation without reduction in opera-        Acknowledgement
tive time. So, the authors have been using the LigaSure                The authors wish to thank Professor Amnuay
device with the help of bipolar forceps and Hem-o-lok         Thithapandha for his help and advice concerning the
5 and 10 mm to provide a precise dissection and an            preparation of this manuscript.
excellent control of vascular pedicles. In some reported
series(7,12-14) the vesical and prostatic fibrovascular       References
pedicles are controlled with sequential firings of the         1. Dalbagni G, Genega E, Hashibe M, Zhang ZF,
Endo-GIA stapler without previous incision of the                 Russo P, Herr H, et al. Cystectomy for bladder
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In the authors’ opinion, previous incision of the endo-           1111- 6.
pelvic fascia and ligation of the dorsal vein complex by       2. Parra RO, Andrus CH, Jones JP, Boullier JA.
1-0 Monocryl absorbable stitch intracorporial(8,9) is             Laparoscopic cystectomy: initial report on a new
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The authors’ technique has provided an anatomic ap-               Loening SA. Laparoscopic radical cystectomy
proach, which is familiar to most urologists, and ana-            with continent urinary diversion (rectal sigmoid
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with that of highly experienced surgeons. However, it             Rosado A, Gutierrez de la Cruz JM, Jimenez Garrido
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are not reduced by the external reconstruction of a            6. Denewer A, Kotb S, Hussein O, El-Maadawy M.
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ible and indicated for patients affected by clinically            World J Surg 1999; 23: 608-11.
organ-confined invasive bladder cancer. It is believed         7. Gill IS, Fergany A, Klein EA, Kaouk JH, Sung GT,
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         Radical cystectomy remains the gold standard          8. Turk I, Deger S, Winkelmann B, Schonberger B,
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less postoperative pain, more precise dissection and           9. Gaboardi F, Simonato A, Galli S, Lissiani A, Gregori


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                           ้          ั     ้ ่
การผ่าตัดกระเพาะปัสสาวะในผูชายแบบเรดิคล ในผูปวยมะเร็งกระเพาะปัสสาวะโดยใช้การผ่าตัด
ผ่านกล้อง: รายงานแรกในประเทศไทย

      ั       ั                       ู
กิตติณฐ กิจวิกย, สุเทพ พัชรตระกูล, วิสตร คงเจริญสมบัต,ิ จรัสพงศ์ ดิศรานันท์

         รายงานการผ่าตัดกระเพาะปัสสาวะในผู้ชายแบบเรดิคัล ในผู้ป่วยมะเร็งกระเพาะปัสสาวะ โดยใช้การผ่าตัด
ผ่านกล้อง สำเร็จเป็นรายแรกของคณะแพทยศาสตร์โรงพยาบาลรามาธิบดี และเป็นรายงานแรกในประเทศไทย
โดยมีการวิเคราะห์เกี่ยวกับเทคนิคการผ่าตัด ผลการรักษา โดยเทียบเคียงกับวารสารทางการแพทย์ของต่างประเทศ
ที่รายงานก่อนหน้านี้


J Med Assoc Thai Vol. 88 No. 12 2005                                                                         1951